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Provider Participation Request
Thank you for your interest in becoming a Quartz participating provider. Your application will be evaluated for participation in all Quartz affiliated networks.
Facility Information
Legal Entity Name:
*
Tax ID:
*
Same as Legal Entity Name?
Name of d/b/a (if applicable):
Website:
Phone Number:
*
Fax Number:
Mailing Address:
*
City:
*
State:
*
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Zip Code:
*
Primary Contact Information
Primary Contact Full Name:
*
Phone:
*
Email:
*
General Information
Total Number of Locations:
Total Number of Practitioners:
Medicare Certified Facility:
*
Yes
No
Total Number of Medicare Certified Practitioners:
Medicaid Certified Facility:
*
Yes
No
Total Number of Medicaid Certified Practitioners:
Facility Type:
*
Hospital
Clinic
Nursing Home
Surgery Center
Behavioral Health Inpatient/Residential
ACA Essential Care Provider
Other
Practice Specialties
Specialty Type:
*
PCP
Specialty
Behavioral Health
Optometry
OT/PT/Speech
Autism
Dialysis
Other
Describe the services you provide:
*
Primary hours of operation:
After hours/emergency call process:
Facility Accessibility
Is the exterior of your facility location/building accessible for people with physical disabilities?
*
Yes
No
Is the interior of your facility/office accessible for people with physical disabilities?
*
Yes
No
Are your exam rooms accessible for people with physical disabilities?
*
Yes
No
Does your office have equipment to accommodate for people with physical disabilities?
*
Yes
No
Does your office have restrooms to accommodate for people with physical disabilities?
*
Yes
No
*Indicates a required field
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